There are several ways of understanding how people can become addicted to drugs. It has been described as a brain disease, as a developmental learning disorder, or simply as a bad habit. When construed as a habit, addiction is always understood to be a condition from which addicts could free themselves by an always possible, if seldom made, sustained effort of will.
Addiction as a brain disease is the view most widely shared by healthcare professionals today. What makes drugs addictive, says Dr. Nora Volkow, director of the National Institute on Drug Abuse, is that they “increase dopamine in brain reward regions.” They hijack the reward-motivation conditioning in the brain, according to recent studies. With many diseases, we don’t put the responsibility for illness on the sufferer, and we should not for drug addiction either, Volkow argues.
At the opposite end of the spectrum are psychologists who believe addicts can and do make rational decisions, and can choose to stop taking drugs. One is Gene Heyman of Boston College, who has written that most addicts “quit using illegal drugs by about age 30” and do so “without professional help.” Dr. Heyman listed “the correlates of quitting” as “legal concerns, economic pressures, and the desire for respect, particularly from family members,” among other factors.
A major proponent of the view that drug addiction is a developmental-learning disorder—which falls somewhere between the aforementioned stances—is a former cocaine addict, the neuroscientist and professor of developmental psychology, Marc Lewis, who emphasizes what he calls “neuroplasticity,” and “the brain’s capacity to change.” This last matches the approach taken by journalist Maia Szalavitz in her new book Unbroken Brain: A Revolutionary New Way of Understanding Addiction.
Szalavitz writes: “The idea that learning matters in addiction is uncontroversial and has been accepted by every type of scientist who studies the condition and by many who treat it for decades.”
That the role played by learning in addiction has been long recognized belies the author’s claim to offer here “a revolutionary new way” of conceiving this problem. Her real point seems to be that the policy implications she draws out are new and revolutionary.
Certainly, were all her recommended policies adopted in the United States, it would rapidly become a very different place, although it must be said it seems intent these days on heading in the direction which Szalavitz wishes it travel without any assistance from her. Majorities in several U.S. states, for example, have voted to legalize marijuana.
To curb addiction, Szalavitz advocates abandoning criminal law sanctions against addicts; adopting a harm-reduction approach through opioid maintenance programs rather than jail or mandatory non-opioid treatment; and setting aside of 12-step programs that advocate abstinence in favor of secular treatment programs and the dispensing of serotonin-enhancing antidepressants to former addicts with clinical depression.
Her support for the efficacy of these policies is questionable, however. In opposing criminal sanctions against addicts, Szalavitz confidently asserts:
If punishment worked to fight addiction, the condition itself couldn’t exist. . . . One policy change that is completely supported by existing data is decriminalizing low-level possession and personal use of all drugs. Arresting and jailing users makes no more sense and is no more effective for heroin and cocaine users than it is for marijuana users.
On the contrary, criminal law sanctions against addicts can and do help to get them quit. According to a 2012 monograph published by Dr. Volkow’s institution, the National Institute on Drug Abuse:
Research has demonstrated that individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily . . . The most effective models integrate criminal justice and drug treatment systems and services.
In advocating harm-reduction through opioid replacement, Szalavitz remarks that:
even as far back as the 1980s, it was the only treatment known to reduce injection drug use and related mortality significantly in the long run. . . Maintenance treatments are the only therapies that can lower mortality by 75%.
But the claim that methadone replacement lowers mortality by more than non-opioid forms of treatment do was not borne out by a comprehensive meta-analysis of published studies of their comparative efficacy of these approaches published by the state of Oregon in 2009. It found that:
Methadone . . . retains patients in treatment and decreases heroin use better than treatments that do not utilise opioid replacement therapy . . . [However, this effect] does not show a statistically significant superior effect on criminal activity or mortality.
Simply being able to keep heroin addicts off heroin better than do non-opioid treatments is no great merit for methadone treatment given how harmful this opioid is. A Scottish researcher, Neil McKeganey (link no longer available), studied Scotland’s extensive long-running methadone replacement program and reports that “Consistently we are seeing around a third of all addict deaths are linked to methadone.” Similar concerns have recently been voiced in Canada about its extensive methadone replacement program.
No better warranted is her statement that “great harm has been inflicted by trying to force 12-step morality into a medical and criminal justice system,” or her complaint about “indoctrination into 12-step ideology.”
The fact is that courts in the United States have long recognized traditional 12-step programs to be religious and hence not ones in which the law can compel anyone to participate. The U.S. Department of Justice has made this clear, and indeed, Section 2 (h.i) of Executive Order 13559, issued by President Obama in 2010, expressly stipulated as much:
If a beneficiary or prospective beneficiary of a social service program supported by Federal financial assistance objects to the religious character of an organization that provides services under the program, that organization shall, within a reasonable time after the date of the objection, refer the beneficiary to an alternative provider.
Equally questionable is the author’s suggestion that these programs discourage their participants from taking all drugs. Such discouragement is expressly condemned by Alcoholics Anonymous, the source of all 12-step programs. The 2011 edition of AA’s officially approved booklet states:
Just as it is wrong to enable or support any alcoholic to become re-addicted to any drug, it’s equally wrong to deprive any alcoholic of medication, which can alleviate or control other disabling physical and/or emotional problems.
However, there are medications and medications. The author is an advocate of the use of Zoloft for treating post-addiction depression. Yet she fails to mention the class action suit that its manufacturer Pfizer is currently facing for having allegedly failed to warn pregnant women adequately about the dangers of its use. Nor does she mention the numerous other complaints that have been made about Zoloft’s other adverse side-effects and those of similarly acting antidepressants.
On the other hand, seeing as Szalavitz was funded to write her book through a Soros Justice Fellowship and how commercially involved her ultimate benefactor George Soros is and has long been with Pfizer, as well as with the development of genetically modified strains of marijuana for commercial cultivation, maybe her promotion of the use and/or the legalization of certain drugs is not so curious.
Yet the source of funding for Szalavitz’s book and its lack of balance do make one wonder where journalism ends and advocacy begins.